October is the month of “breast cancer awareness” which takes place internationally, including the Emirates. It is therefore an appropriate time to take a more detailed look at what happens when breast cancer has been diagnosed: the treatment options and particularly the possibility of breast reconstruction following surgery, which provides many women of today with the opportunity to regain their femininity and return to a full, productive life following treatment for this most distressing disease.
Although nothing can take the place of a one to one consultation, here Dr Allen Rezai, a leading Consultant Plastic & Reconstructive Surgeon specialised in various types of breast reconstruction including the advanced autologous tissue reconstruction requiring microsurgical skills, shares with you some common questions he hears from his patients in regards to breast reconstruction:
Q: When is Breast Reconstruction Done?
A: Breast reconstruction can be done at different times, depending on your circumstances and stage of your cancer.
Immediate reconstruction – which means you have the reconstruction surgery at the same time as your mastectomy. Patients who chose prophylactic (preventative) mastectomy or those who are diagnosed with stage I or some stage II cancer are generally good candidates for this option. In some cases, this option may even be appropriate for stage III and IV cancer patients, in this case, your oncologist and plastic surgeon will discuss this with you.
Delayed Reconstruction – Is when the reconstructions had months or even years after mastectomy. The reasons can be anywhere from the patient preference or the need of various cancer treatments which would need for the reconstruction to be delayed.
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Q: What are my options for breast reconstruction?
A: The options and timing for breast reconstruction depend on each patient’s circumstances and preferences. The options vary from the use of implants, through to the latest techniques of autologous (living) tissue reconstruction, in which the patient’s own tissue from another part of the body is transferred to the chest area to create the new breast. Sometimes a combination of implant and patient’s own tissue is required to achieve optimum results.
Autologous tissue reconstruction produces breasts with the most natural look and feel, and they will remain with a woman for life, whereas silicone or saline implants will eventually need replacing. I prefer to use the techniques of autologous tissue reconstruction when possible but some patients do not have the right indications for this option or simply prefer the option of implant breast reconstruction. Sometimes patients also chose to have their nipples reconstructed as well.
Q: Is there only one type of autologous breast reconstruction?
A: No, there are numerous types of living tissue reconstruction depending on the donor site and the kind of tissue “flap” being used. There are two main types of reconstruction techniques, Muscle Flap reconstruction, also known as Pedicle flap, and those involving Perforator Flaps, the latter being the most advanced methods of autologous reconstruction and requiring microsurgical expertise. In all perforator flaps, a "free flap" technique is used. This means that a flap consisting of skin, fatty tissue and tiny blood vessels that supply nutrients to the tissue is completely detached from the surrounding tissues at the donor site, transferred to the breast reconstruction site, and the blood vessels are then re-connected to vessels close to the breast using microsurgical techniques, ensuring that the flap receives the blood supply necessary for survival.
Muscle flaps, on the other hand, as the name suggests, include part of the muscle from the donor site. and is transferred using a free or pedicle (attached) technique, meaning that the muscle is only partially removed, to retain the flap’s blood supply during and after the transfer. Although this procedure still requires expertise, it is not as advanced as Free perforator flap technique which requires the surgeon to employ microsurgery to reconnect the blood vessels for the survival of the reconstructed breast.
Muscle Flaps were generally used in an era well before perforator flap techniques were developed. In comparison to muscle flaps, the perforator flaps are less damaging to the donor site, as the muscle stays intact which results in no post-operative muscle weakness in the donor site and a faster recovery.
A patient with an active lifestyle who plays sports would particularly benefit from a Free Flap reconstruction as she may resume her active lifestyle without any complications once the healing process is complete.
Q: What is DIEP breast reconstruction?
A: DIEP flap is the most common and preferred free perforator flap. DIEP stands for Deep Inferior Epigastric Perforators which are the tint blood vessels that run through the abdomen.
In a DIEP flap reconstruction, fat, skin, and tiny blood vessels are detached from the wall of the lower abdomen and transferred to the chest then the blood vessels of the flap are carefully reattached to blood vessels in the chest using microsurgery. Because no muscle is used, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to muscle flaps like TRAM, transverse rectus abdominis muscle.
Similar to all perforator flaps, DIEP flap procedure requires special surgical training as well as expertise in microsurgery, hence, not all surgeons can offer DIEP reconstruction. My team and I have a vast amount of experience in microsurgical reconstructions not only involving the breasts but also in head and neck, trauma, burn and hand surgery. We are all trained and highly experienced in Perforator Flap techniques and prefer these techniques to others since we believe it will provide the patient with the best possible outcome and freedom to live her life as she wishes without any physical obstacles holding her back.
Perforator Free Flap Reconstruction such as DIEP flap procedure may not be very common in the Middle East but it is commonly performed in other parts of the world, and it is usually the 1st option given to the patient if the patient has an indication for this type of breast reconstruction.
Click on the image above, to view an educational video of an actual DIEP breast Reconstruction Surgery performed by Dr Allen Rezai and his team.
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Q: How will I know which option is good for me?
A: Many factors should be taken into consideration when deciding on a suitable option.
These factors include:
How much breast tissue has been removed during mastectomy,
The health of the breast tissue and those of other areas of the body that may be used as donor sites
Whether the patient has had or plan to have radiotherapy to the breast or chest wall
The shape and size of the breasts
Patient’s general health and body build
During the initial consultation, I always discuss all available options with my patients, including pros, cons and the implications of each option, then based on my examination and above factors recommend the method or methods which would achieve the best possible results and leave it up to my patient to decide how she’d like to proceed.
Q: Will I have visible scars?
A: Your scars will depend mainly on how your mastectomy is performed, and the type of reconstruction you have. The shape and size of the mastectomy scars will vary between immediate and delayed reconstruction. For immediate reconstruction (performed at the same time as mastectomy), it is often possible to perform what is known as a nipple- or skin-sparing mastectomy which will result in either a circular scar around the nipple and areola or a relatively small straight line scar. However, for delayed reconstruction (performed in a separate operation at some time after the mastectomy), more skin is removed at the time of mastectomy leaving a long scar pronounced scar across the chest wall (breast). It is important to realise that although all scars will fade with time they will never entirely disappear.
Q: I had a mastectomy three years ago; can I still have reconstruction?
A: Yes, delayed reconstruction using implants or your own tissue can be had at any time after your mastectomy.
Q: Can I still have reconstruction if I am having a prophylactic mastectomy?
A: Yes and the best option would be immediate reconstruction as after elective mastectomy this option can produce excellent aesthetic results.
Q: When can I have my nipples reconstructed and is it necessary?
A: Generally, the nipple and areola are removed during mastectomy as a precaution against leaving lingering cancer cells behind, unless you have a nipple-sparing mastectomy and immediate reconstruction after which you will have your own natural nipples on your reconstructed breast but with possibly diminished sensation and response. If your nipples must be removed then nipple reconstruction can be performed during an immediate reconstruction, but is more commonly performed 4-6 months after the breast reconstruction is complete.
Before deciding to undergo nipple reconstruction, there are several factors to consider about the new nipple. The reconstructed nipple will not react in the same way to temperature changes or touch; it will not have the same sensation as a natural nipple; it will not grow and flatten as natural nipples do; and it will have no feeling. But in spite of these drawbacks, it makes a significant contribution to the overall naturalness of the new breast.
Nipple reconstruction is certainly not a necessity, it is rather a choice. Some patients chose to not have their nipples reconstructed and are happy with how they are or opt for only tattoo instead.
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Q: How long is the reconstruction process?
A: The timeline varies depending on the type of reconstruction, mastectomy, and whether further cancer treatments are needed. It generally may take up to 3 months or one year to complete the reconstruction process, that is if no further cancer treatment is necessary.
For example, a DIEP reconstruction can be done in one or two stages depending on whether it is immediate or delayed. And for implant breast reconstruction again, it can be done in one or two stages depending on the type of mastectomy, use of tissue expander and need of cancer treatment.
Timeline of the reconstruction procedure is thoroughly discussed during the consultation but generally here are the steps that are followed:
1st Step: First surgery to create a breast. Can be had at the same time as the mastectomy (immediate) or at a later date after the mastectomy (delayed). Wait about three to 6 months for healing. Increase this time if any chemotherapy or radiation therapy is needed. In most cases of nipple-sparing mastectomy and immediate implant-based breast reconstruction, this is the only step required.
2nd Step: Further surgery, including fat transfer, to make any changes to refine or balance the reconstructed breast. Wait about two to three months for healing. This step may be repeated as needed.
3rd Step: Surgery to reconstruct nipple and areola, only applies to patients who did not have a nipple-sparing mastectomy and /or who choose to have nipple reconstruction.
Q: Will I need Surgery on my healthy breast?
A: The ultimate goal in breast reconstruction is to create a breast that is symmetrical with the remaining natural breast. Hence patients having breast reconstruction following a mastectomy at one side only may also require surgery on the opposite breast in order to make the breasts more symmetrical and to achieve optimal cosmetic results.
There are essentially five available options:
Firstly, to have no surgery on the other breast. Many patients may feel having surgery on a healthy breast is unacceptable and would prefer a form of reconstruction that best matches the existing breast without any change.
Secondly, to enlarge the remaining breast. If the reconstructed breast is larger than the other breast and the larger breast is preferred, then the natural breast can be made bigger with an implant.
Thirdly, it is possible to Lift the remaining breast. If the natural breast is more droopy than the reconstructed breast, it can be lifted and reshaped. A breast lift adjusts the shape and position of the breast and nipple without changing its size.
Then there is the option of reducing the remaining breast. If the natural breast is larger than the reconstructed breast, it can be reduced in size and altered in shape so that the final appearance is balanced.
And finally, there is the option to remove the other breast and reconstruct both of the breasts. In certain circumstances, bilateral mastectomy may be recommended either due to there being cancer in both breasts or as a prophylactic measure in high-risk patients
Q: Do I have to have breast reconstruction?
A: The simple answer is no, but I strongly believe that breast reconstruction plays an important factor in a woman’s psychological and physical recovery after having a mastectomy; however, it is the individuals’ choice to undergo a breast reconstruction. Some patients decide that they are not ready to have reconstruction for various reasons, or do not want to undergo any further surgeries. Many breast cancer patients may choose to wear a prosthesis (artificial breast) to allow a better fit in clothing and minimise the lopsided feeling that the missing breast tissue or breast may create for some patients after cancer surgery.
But as a surgeon, I have a responsibility to provide patients with ALL the treatment options available to them, explain the advantages and disadvantages of each option and leave it up to them to make an informed decision. After all, this is a life changing procedure for a patient and I believe that she should be involved in the decision-making process from start to finish.
Living a long cancer-free life is the optimal goal, but retaining your femininity is just as important.
Q: Is there any alternative to breast reconstruction surgery?
A: Yes as with all elective procedures there is always the option of not having the procedure. However, having their breasts reconstructed makes many cancer patients feel better about their appearance and benefits them emotionally and psychologically. But, some patients may not be good candidates for reconstruction, perhaps due to other health issues, or that they simply do not want to put themselves through further surgery after a mastectomy. This is entirely understandable.
In these cases, there is the option of wearing an external prosthesis which is usually made of synthetic foam material that can be placed inside a custom-made bra to match the opposite breast. Or they can be made for both breasts. When normal fitting clothes are worn, most people are unable to tell the difference. However, the prosthesis can sometimes be uncomfortable to wear, particularly when hot outside or when certain types of clothes are worn.
Q: Any final advice?
A: Breast reconstruction is a highly personal choice and the decision process can seem overwhelming. It can sometimes mean undergoing multiple or accompanying procedures. It is important to think both short and long-term. Work with your doctors and plastic surgeon to thoroughly discuss and plan your treatment. A few of the things to consider while planning includes: the stage of your breast cancer and any adjunct treatments, your general health and healing ability, your breast size and whether one or both breasts will be reconstructed, your preferences for balance and shape, elected procedures, your downtime, and costs. It is important to take the time to consider your options so you can feel confident about what you decide.
For further information about Breast Reconstruction or a Consultation with Dr Allen Rezai call +971 4 431 2396.